【作者】 吴磊；

【导师】 蒋琪霞；

【作者基本信息】 南京大学 ， 护理（专业学位）， 2020， 硕士

【摘要】 【目的】本研究通过观察比较2种滴注式负压伤口治疗对后期需行皮片移植手术治疗的全层皮肤缺损伴感染伤口患者的术前伤口床准备效果,包括细菌培养结果、压疮愈合计分、一次植皮手术成功率等指标。通过比较3组疗效差异,为后期改进与临床推广滴注式负压伤口治疗提供理论与依据。【方法】本研究选取2019年1月至2019年12月于南京大学医学院附属金陵医院伤口护理中心及烧伤整形科就诊的全层皮肤损伤的感染伤口患者作为研究对象。患者满足纳排标准、签署知情同意书后入选本研究,根据探索性随机对照研究原则,纳入的90例患者被随机分配入负压治疗组(对照组)、持续滴注负压组(试验组1)、间歇滴注负压组(试验组2),所有入组患者在完成清创治疗后根据分组情况予以不同干预措施,负压治疗组给予单纯负压伤口治疗,持续滴注负压组给予持续生理盐水滴注+持续负压伤口治疗,间歇滴注负压组给予持续生理盐水滴注+间歇负压伤口治疗,干预0天、7天与14天分别对3组患者进行伤口细菌培养和压疮愈合计分量表评估,干预过程中及时记录不良事件,包括管道堵塞与负压装置失效。所有患者在完成14天的分组干预后由临床医师评估手术时机并完成皮片移植手术,术后随访至患者痊愈出院并记录3组患者的一次手术成功率,所有数据均采用SPSS 22.0软件进行数据录入与统计分析。【结果】本研究共纳入符合条件的患者90例,所有患者均完成伤口清创、试验干预、手术治疗与术后随访。(1)基线资料比较:负压伤口治疗组、持续滴注负压组与间歇滴注负压组患者在年龄、性别、营养情况、感染状况、基础疾病等一般基线资料上均无统计学差异(P>0.05),在伤口类型、伤口部位、伤口面积等伤口特征资料上亦无统计学差异(P>0.05),以上数据表明基线资料具有可比性;(2)伤口床细菌培养结果的比较:负压伤口治疗组、持续滴注负压组与间歇滴注负压组干预0天细菌培养阳性率分别为90.00%、86.67%与90.00%,差异无统计学意义(P=1.000),伤口平均菌种数为1.63±0.85、1.47±0.86与1.50±0.731,差异无统计学意义(P=0.705);干预7天后细菌培养阳性率分别86.67%、80.00%与76.47%,差异有统计学意义(P=0.020),伤口平均菌种数为1.50±0.90、1.23±0.86与0.43±0.50,差异有统计学意义(P=0.000);干预14天后细菌培养阳性率分别为83.33%、46.67%与11.11%,差异有统计学意义(P=0.000),伤口平均菌种数为1.60±0.89、0.50±0.63与0.10±0.31,差异有统计学意义(P=0.000)。(3)压疮愈合计分量表的比较:负压伤口治疗组、持续滴注负压组与间歇滴注负压组在干预0天压疮愈合计分量表评分分别为15.73±0.87、15.67±0.71与15.93±0.91,差异无统计学差异(P=0.439);干预7天后评分分别为14.53±1.17、14.97±1.13与13.53±0.90,差异有统计学意义(P=0.000);干预14天后评分分别为14.20±1.19、14.27±1.02与12.47±1.04,差异有统计学意义(P=0.010),对干预0天、干预7天与干预14天的压疮愈合计分量表评分采用连续测量的方差分析发现,干预14天后3组差异有明显统计学差异(P=0.000)。(4)一次手术成功率的比较:90例患者随访至痊愈出院,负压伤口治疗组、持续滴注负压组与间歇滴注负压组的一次手术成功率分别为33.33%、40.00%与70.00%,差异有统计学差异(P=0.010)。(5)不良事件的比较:负压伤口治疗组、持续滴注负压组与间歇滴注负压组在14天的干预过程中平均管道堵塞率分别为60.00%、23.33%与26.67%,差异有统计学意义(P=0.005),平均堵塞次数为0.87±0.90、0.07±0.25与0.10±0.31,差异有统计学意义(P=0.000);平均负压失效率分别为10.00%、20.00%与23.33%,差异无统计学意义(P=0.372),平均负压失效次数分别为0.10±0.31、0.27±0.64与0.40±0.81,差异无统计学意义(P=0.180)。【结论】与单纯负压伤口治疗比较,滴注式负压伤口治疗能够显著降低伤口床细菌培养阳性率与菌种数,降低压疮愈合计分量表评分,提高一次手术成功率,且未明显增加不良事件的发生率。间歇滴注负压伤口治疗可完成完整的负压冲洗过程,实现了冲洗溶液与伤口床的充分接触与冲洗溶液的停留,因而可达到最佳的冲洗效果,抑制细菌繁殖,完善术前伤口床准备,提高一次皮片移植手术成功率。更多还原

【Abstract】 【Objective】This study is aimed at comparing the effect of two models of negative pressure wound therapy with instillation in preoperative wound bed preparation of the infected wounds with full-thickness skin lesions,including bacterial culture outcomes,pressure sore healing score,success rate of one-time surgery and other indicators.By comparing the difference of effect between the three groups,it would provide theory and basis for improving and popularizing the negative pressure wound therapy with instillation.【Method】This study selected the patients with infected wounds which had fullthickness skin lesions from Burn and Plastic surgery and Wound Care Centre,Jinling hospital affiliated to Medical college of Nanjing university between January 2019 and December 2019.The patients who met the standard of inclusion and exclusion and signed the informed consent were selected into this study.According to the exploratory randomized controlled study principle,the selected patients were randomly divided into the negative pressure wound therapy group(Control group),the negative pressure wound therapy with continuous instillation group(Treatment group 1),and the negative pressure wound therapy with intermittent instillation group(Treatment group 2).All of the patients wound be given different interventions according to the grouping situation after the complete debridement.The negative pressure wound therapy group was given negative pressure wound therapy alone,the negative pressure wound therapy with continuous instillation group was given continuous negative pressure wound therapy + continuous instillation of normal saline,the negative pressure wound therapy with intermittent instillation group was given intermittent negative pressure wound therapy+ instillation of normal saline.All the patients from 3 groups were evaluated by wound bacterial culture and pressure sore healing score scale on 0 days、7 days and 14 days of the intervention.Adverse events were recorded in time during the intervention,including pipeline blockage and negative pressure device failure.All patients’ operation time were evaluated by the surgeon after the 14-day subgroup intervention and the skin graft was completed.The patients were followed up until they were cured and discharged after operation,and success rate of one-time surgery was recorded in the three groups.All data were recorded with SPSS 22.0 software for data entry and statistical analysis.【Results】The study included 90 patients who met the standard of inclusion and all the patients completed wound debridement,experimental intervention,operation and postoperative follow-up.(1)The baseline data comparison: negative pressure wound therapy group,negative pressure wound therapy with continuous instillation group and negative pressure wound therapy with intermittent instillation group in age,gender,nutrition situation,infection status,basic diseases and other baseline data were no statistical difference(P> 0.05).In the wound type,wound parts and wound area such as characteristics of wound also showed no statistical difference,(P> 0.05).The above data show that the baseline data were comparable;(2)Comparison of bacterial culture outcomes in wound bed: the positive bacterial culture rates of negative pressure wound therapy group,negative pressure wound therapy with continuous instillation group and negative pressure wound therapy with intermittent instillation group respectively were 90.00%,86.67% and 90.00% on the 0 day of intervention with no statistical significance(P=1.000).The average number of wound bacteria species was 1.63±0.85,1.47±0.86 and 1.50±0.731 with no statistical significance(P=0.705).The positive rate of bacterial culture after 7-days intervention was 86.67%,80.00% and 76.47% with statistically significant differences(P=0.020).The average number of wound bacteria species was 1.50±0.90,1.23±0.86 and 0.43±0.50 with statistically significant differences(P=0.000).The positive rate of bacterial culture after 14-day intervention was 83.33%,46.67% and 11.11% with statistically significant differences(P=0.000).The average number of wound bacteria species was 1.60±0.89,0.50±0.63 and 0.10±0.31 with statistically significant differences(P=0.000).(3)Comparison of pressure sore healing score scale: the scores of pressure sore healing score scale of negative pressure wound therapy group,negative pressure wound therapy with continuous instillation group and negative pressure wound therapy with intermittent instillation group before intervention were 15.73±0.87,15.67±0.71 and 15.93±0.91,respectively with no statistical difference(P=0.439).After 7-days intervention,the scores were 14.53±1.17,14.97±1.13 and 13.53±0.90 with statistically significant differences(P=0.000).The scores after 14-days intervention were 14.20±1.19,14.27±1.02 and 12.47±1.04 with statistically significant differences(P=0.010).The continuous measurement analysis of variance(anova)was used to measure the scores of pressure ulcer healing score scale on 0 day,7 days and 14 days of intervention,and it found statistically significant difference between the three groups on 14 days of intervention(P=0.000).(4)Comparison of success rate of onetime surgery: 90 patients were followed up until they were cured and discharged.Success rate of one-time surgery of negative pressure wound therapy group,negative pressure wound therapy with continuous instillation group and negative pressure wound therapy with intermittent instillation group were 33.33%,40.00% and 70.00% with statistical differences(P=0.010).(5)Comparison of adverse events: during the 14-day intervention,the average rate of pipeline blockage in negative pressure wound therapy group,negative pressure wound therapy with continuous instillation group and negative pressure wound therapy with intermittent instillation group were 60.00%,23.33% and 26.67% with statistically significant differences(P=0.005).The average number of blockage was 0.87±0.90,0.07±0.25 and 0.10±0.31 with statistically significant differences(P=0.000).The rates of negative pressure device failure were 10.00%,20.00% and 23.33% with no statistically significant difference(P=0.372).The average number of device failure times were 0.10± 0.31,0.27±0.64 and 0.40±0.81 with no statistically significant difference(P=0.180).【Conclusion】Compared with negative pressure wound therapy,negative pressure wound therapy with instillation can significantly reduce the positive rate of bacterial culture and the number of bacteria species in the wound bed,reduce the score of pressure sore healing scale,improve success rate of one-time surgery and do not significantly increase the incidence of adverse events.The negative pressure wound therapy with intermittent instillation group can complete the complete process of negative pressure wound therapy with instillation and realize the full contact between the instillation solution and the wound bed and the retention of the instillation solution,so as to achieve the best instillation effect,inhibit bacterial reproduction,improve the preoperative preparation of the wound bed,and improve the success rate of skin graft operation.更多还原